Welcome to the State of California 

Monitoring Adherence to Healthcare Practices
that Prevent Infection

Most healthcare facilities have infection control and prevention policies and procedures.  However, do you know if all healthcare providers understand and are consistently complying? The California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program developed tools for measuring healthcare worker adherence to care practices critical to prevent infections.  Each hospital, skilled nursing facility, and outpatient clinic should develop a plan to regularly monitor staff adherence to evidence-based infection prevention practices.  Feedback of adherence monitoring results to frontline staff can increase compliance and prevent HAI. 

We present 20 adherence monitoring tools for measuring care practices, including contact precautions, environmental cleaning, hand hygiene, invasive device use, perioperative care, blood glucose monitoring, injection safety, hemodialysis care, and reprocessing reusable devices.  Suggestions for using the tools:

  • Covert observations (e.g., using “secret shoppers”) are more effective than overt observations for assessing routine, typical care.  Monitoring by a known designated staff member, such as the infection preventionist, may result in inflated adherence percentages. 
  • When using an adherence monitoring tool, repeat the measurements at regular intervals to assess improvement over time.  Sharing performance data that demonstrates improvement over time is important to gain frontline support for infection prevention interventions.
  • Encourage competition between units to achieve higher adherence percentages.  

Calculating adherence percentage

The method used to calculate the adherence percentage is the same for each adherence monitoring tool. On the form, you will sum the number of correct practices observed and divide by the total number of observations (and multiple by 100).

Example:          6 staff were observed correctly following contact precautions practices               x100 = 60% adherence
                    A total of 10 staff were observed entering/exiting a contact precaution room

Personal Protective Equipment

Contact Precautions

Reduction of C. difficile and other multi-drug resistant organisms (MDRO) requires strict adherence to contact precautions and proper use of personal protective equipment. Use this tool to determine if staff members are correctly adhering to contact precautions practices. Feedback of results to staff has been shown to increase adherence to these practices.

Contact Precautions Adherence Monitoring Tool 

CDC 2007 Guidelines for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings

CDC Guidance for the Selection and Use of Personal Protective Equipment in Healthcare Settings

Environmental Services

Environmental Services

Pathogens are transmitted in healthcare settings when contaminated surfaces and equipment are not adequately cleaned and disinfected between patients.  Use this tool to measure how well staff members are adhering to appropriate environmental cleaning and disinfection practices.  Feedback of results to staff has been shown to increase adherence to these practices.

Environmental Services Adherence Monitoring Tool 

CDC Guidelines for Environmental Infection Control in Healthcare Facilities

CDC Options for Evaluating Environmental Infection Control

Hands Washing

Hand Hygiene

Regular monitoring with feedback of results to staff can improve hand hygiene adherence. Use this tool to identify gaps and opportunities for improvement. Monitoring may be performed in any type of patient care location.

Hand Hygiene Adherence Monitoring Tool  

CDC Guideline for Hand Hygiene in Healthcare Settings 

Central Line Equipment

Central Line Adherence Monitoring

A central line associated bloodstream infection (CLABSI) may occur due to breaches in technique during line insertion or lapses in infection prevention practices when accessing and maintaining the line. We provide three central-line adherence monitoring tools for direct observation of 1) the central line insertion process, 2) central line medication administration and dressing changes, and 3) the condition of the central line dressing and tubing.

Central Line Insertion Practices Adherence Monitoring Tool

Central Line Access and/or Dressing Change Practices Adherence Monitoring Tool

Central Line Maintenance Practices Adherence Monitoring Tool 

CDC Guideline for the Prevention of Intravascular Catheter-Related Infections, 2011

Surgery Team

Surgical Site Infections (SSI) - Operating Room Environment

Use these tools to measure adherence to evidence-based practices known to reduce SSI in the operating room and perioperative settings.  Monitoring may be performed in any operating room setting, including hospitals, ambulatory surgery centers, and outpatient clinics.

SSI Prevention/Operating Room Environment Adherence Monitoring Tool 

Environmental Cleaning and Disinfection in the Perioperative Area Adherence Monitoring Tool

CDC Guideline for the Prevention of Surgical Site Infections

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update
Anderson, D.J., et al, Infection Control and Hospital Epidemiology,Vol. 35, No. 6 (June 2014), pp. 605-627 

Urinary Catheter Equipment

Indwelling Urinary Catheter Maintenance Practices

The best ways to prevent a catheter associated urinary tract infections (CAUTI) are to avoid use of indwelling catheter unless absolutely necessary and to remove catheters as quickly as possible after insertion.  Use this tool to observe the conditions of urinary catheters in use, and to identify gaps and opportunities for improvement. 

Indwelling Urinary Catheter Maintenance Practices Adherence Monitoring Tool

CDC Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009 

Glucose Meter

Blood Glucose Monitoring

Incorrect use of or failing to properly disinfect blood glucose meters places patients at risk for bloodborne pathogen infections.  Use this tool to observe blood glucose monitoring practices and identify gaps and opportunities for improvement. Monitoring may be performed in any type of patient care location where blood glucose is monitored. 

Blood Glucose Meter Adherence Monitoring Tool  

CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration

CDC Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration

Syringe with Vial

Injection Safety

Injection safety is a basic expectation in patient care, and includes safe handling of medications and using each needle and syringe for only one patient one time.  Use this tool to measure adherence to safe injection practices in any type of location where medication is prepared or provided to patients.  Adherence monitoring will help to identify areas for potential harm to patients or healthcare workers.

Injection Safety Adherence Monitoring Tool  

CDC Injection Safety Web Materials


Hemodialysis Equipment


Use these hemodialysis tools to measure adherence to dialysis care practices that are important for the prevention of bloodstream infections and access site infections. 

Hand Hygiene

Catheter Connect/Disconnect 

CDC Catheter Exit Site Care

CDC Injectable medication preparation and administration

CDC Fistula/graft connect/disconnect

CDC Dialysis station cleaning/disinfection

Device Reprocessing Equipment

Device Reprocessing

Many areas of the healthcare facility may be performing device reprocessing.  These adherence monitoring tools may be used in any area where device reprocessing, or high-level disinfection or sterilization of reusable devices are performed. Select the monitoring tool that best applies to the reprocessing area being observed.

Device Reprocessing Adherence Monitoring Tool 

High-Level Disinfection of Reusable Devices Adherence Monitoring Tool 

Sterilization of Reusable Devices Adherence Monitoring Tool  

CDC Guideline for Disinfection and Sterilization in Healthcare Facilities

FDA regulations on reprocessing of single-use devices 

 For questions, suggestions, or more information, please email HAIProgram@cdph.ca.gov

Last modified on: 3/27/2017 2:22 PM